The Peer Healing Space Pathways Exploration of Needs Form

INTRODUCTION

The Peer Healing Space 

The Peer Healing Space is a lived experience residential service for people who are experiencing distress or mental health challenges.  

It is a free mental health service that provides short-term care and support in a home-like setting for people aged 18 years or older. People can stay at the service for a few days or up to three weeks. It is run by people with lived and living experience of mental health challenges.  

This service is run by peer workers – people with lived experience of mental health challenges. It provides another alternative to hospital.  

The Peer Healing Space is located in Moolap, Geelong. It has gardens, shared indoor spaces, and room to rest, connect, and heal in your own way.  

A stay at the service is your choice. You do not have to stay if you do not want to and you can leave at any time. There are no uniforms, no locked doors, and no forced treatment. 

You will still be able to access any support you are currently receiving. Planned visits from support staff are welcome. 

What guests can expect  

Support from peer workers with lived experience  
One-to-one support  
Group activities to help you connect with others  
Shared meals and outings in the community  
Support when you are feeling distressed  
Your own bedroom and private bathroom

What we ask from guests  

Work with us to help keep the space safe  
Tell us when you’re coming and going  
Follow the mutuality agreement  
Do not bring alcohol or other drugs on site  
Manage your own medications (if needed)

How The Peer Healing Space is different 

This service is run by peer workers – people with lived experience of mental health challenges. It provides another alternative to hospital.  

You are encouraged to stay connected with existing supports if you have them, and planned visits are welcome between 10am – 8pm to help with this. 

Any support you require with medication will need to be organised through external supports, Peer Mental Health workers do not manage medication, however there is a safe in your bedroom for storage of any medications that you take. 

We don't have AOD specialists on site, so if alcohol or drugs are part of your experience, we will talk about what a stay with us might look like. For this reason, we expect that no alcohol or other drugs will be brought or consumed on site, this is to help make the space safe enough for everyone. 

Interested?  

If this feels like something you are interested in, please complete the referral form so we can get to know you and your support needs a bit better. 

For more information on our community agreement, alcohol and other drugs approach, or medication approach, please read the documents available here.

Your responses will be

used to help improve our services so we can support people better, and  
combined (without identifying you) with responses from other people to understand how well we are supporting people
to help tailor supports to your individual needs, such as offering to be linked in with our Equity and Cultural Wellbeing Coordinator.

Who will see these 

Reports created from this information will not identify you and will be kept within Privacy and Confidentiality laws.

The Peer Healing Space Pathways Exploration of Needs Form - Personal Information

Date of EOI

Are you filling this out for yourself or someone else?

YouSomeone Else

Name

I understand that by submitting this information, I am consenting to Mind Australia’s Peer Healing Space staff contacting me by the phone number and/or email provided. *

I understand that my information will be recorded in line with Mind’s Privacy, Confidentiality, and Consent policies. *

I understand my rights and responsibilities as a potential guest will be discussed with me as part of the referral process.
(See consent form) *

Preferred Contact Method

Preferred First Name *

Preferred Last Name *

DOB *

Phone number *

Are we allowed to text this number, or leave a voicemail?

Is there a preferred time you'd like us to call you?Tick all that apply

Residential Address

Street address

City

State

Postcode

Pronouns

I identify my gender as:

Do you identify as Aboriginal and/or Torres Strait Islander?

Do you identify as an Asylum Seeker or Refugee?

YesNo

Are there any other identities, communities or cultures you belong to that are important for you to advise us on?

Would you like to be linked in with our Equity and Cultural Wellbeing Coordinator?

YesNo

This information is private and confidential and will not be shared beyond the LERS team

What language do you speak at home?

Is an interpreter required/preferred?

YesNo

How did you hear about our service?

Do you have any accessibility needs or things we should know that would facilitate your engagement with us?For example, AUSLAN interpreted sessions, meeting in areas with…

Are you currently experiencing housing insecurity or homelessness?

YesNo

If so are you engaged with any housing support services?

YesNo

The Peer Healing Space Pathways Exploration of Needs Form - Wellbeing and Supports

In the event of an emergency, who is the main person we can contact on your behalf?

Emergency Contact First Name

Emergency Contact Last Name *

What is your emergency contacts contact number? *

What is your emergency contacts email? *

Is there anything further we should know about this contact, e.g. what to disclose/not disclose to them?

Are you currently using recreational drugs or alcohol?

YesNo

If so, could you please let us know what substances, how often and how much?

Do you have any medical physical health conditions or accessibility needs or conditions?

YesNo

If so, please let us know what these needs or conditions are?

Do you have meetings or commitments that you are needing to attend through the course of your stay?

YesNo

If so, please let us know what these meetings or commitments are?

Do you have any physical health needs such as:

AsthmaHeart ConditionsExperiencing seizures

Tick all that apply

If so, do you have a seizure management plan?

YesNo

Do you have a mental health diagnosis that you identify with and would like to disclose?

YesNo

If so is there anything that you think would be helpful for us to know about your experience?

Are you on any medications that would be helpful for us to know about - and if so, how long have you been taking them?

YesNo

These might include blood thinners, asthma puffers, epi pens, insulin, or methadone

Please tell us more about these medications

Are you currently on a Community Treatment Order? *

YesNo

If so, who is your supporting contact? *

If you are on a CTO we need to have a transparent conversation about what these means in our service – and refer to our medication policy.

Would you like to book this now or book in another time?

NowAnother Time

Booking date for conversation

Are you currently engaged with mental health services?

YesNo

If so, are there any contacts you think would be helpful for us to know about?

Do you have any allergies and or food allergies?

YesNo

Please tell us about these allergies

If you are arriving from out of area, do you have medication coordination arranged?

YesNo

This includes scripts, preferred pharmacy etc.

Please tell us more about the medication coordination arrangements

What supports do you currently have in place? These could be formal such as a treating team, or informal such as friends or family.

Preferences

Why are you seeking to connect with the Peer Healing Space?

What would you hope to experience through your time at the Peer Healing Space?

Do you accept phone calls or would you like a text message before ringing?

Do you have an Advanced Statement of Preference?

YesNo

If no would you like to know what one is, and would you like to complete one prior to your stay?

YesNo

Is there anything else you would like to share about who you are or add to the above information?

service

location

Type of Referral

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